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4 , Waste Tire Survey & Inspection Report Inspection Report NumberState ■ <br /> CIWMB 181 <br /> Survey Form - Page 1 i 5 - 01 Q 6 5 4 <br /> CIWMB 181(Naw O4IlLi) <br /> Callfomla Integrated Waste Management Board <br /> Part A-Surve BLUE OR BLACK INK PEN <br /> Business ProfileInspectlon Details _ J <br /> TPID- I >f O I _ O I Inspection Type (Fill one) <br /> Site Suffix: -T ®Routine 0 Reinspection 0 Referral 0 Observation <br /> [ <br /> Local `/ If Referral,choose referral type(Fill one) <br /> Identifier: ��aQJi,K C/ft� p 771 0 CHP 0 CIWMB 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name - -- <br /> / � Inspected By Inspector <br /> 13641 /ul0 r-C. Pn-d <br /> Physical Address 3 q <br /> _r-dQ 04 Inspection Date <br /> Time In V J Time Out <br /> Business Rep GTitle Q AM Q AM <br /> Va� /�"�/�� �1.t/P� 1 l 405 �tIQC�� QPM O PM <br /> siv <br /> —F Operational Status The Type Business Role Storage Type <br /> Tire Count(Whole/PTE) (Fill one only) (Fill all thatapply) (Fill all that apply) (Fill all that apply) <br /> f ®Active ®Passenger 0 Generator ®Outdoor <br /> 0 Closed 0 Altered <br /> GPS Latitude0 Hauler ®Indoor <br /> D 0 Inactive 0 Truck <br /> Longitude _ 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type (Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 0 Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 used Tire Dealer 0 Auto Body •Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B-Inspection of Waste Tire Dealer,Generator,Hauler and End-Use Facility <br /> 0 0 PRC§42951-Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. <br /> 0 0 PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459 -Responsible Entities Complying with Manifesting Requirements <br /> 0 0 14 CCR§18459.1(a)(b)(c)-Tire Program ID Number from CIWMB <br /> 0 0 14 CCR§18459.2.1-Submittal of Manifest Forms and Tire Trip Logs within 90 days <br /> 0 0 14 CCR§18459.3-Retention of Manifest Forms and Tire Trip Logs for 3 years <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers <br /> 0 0 14 CCR§18461-Manifest System Requirements for Waste Tire End-Use Facilities <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators <br /> 0 0 [Other. § <br /> Comments¢?.,,1I!1 Sri`A S do A I,i Aa _ <br /> WA ✓ LU -[ _ -ti✓e - GL'c'& oS 4. Vj <br /> Inspection Form Included:0 Qr�/ 71 �Q� <br /> Comments Included:0- �+`q_q 7 3� 7 & <br /> Busl s Re nature Phone Number I tor's g a ure. Phone Number <br /> . INSTRUCTIONS ON B K jEjXjA1M1kL1Ej I1 '2 3 62081 <br /> White Copy.CIWMB Yellow Copy:Operator Pink Copy'LEA ® ■ <br /> 0711604.0155 <br />